HospitalInspections.org

Based on findings from medical record (MR) review, document review and interview, in 5 of 5 MRs of patients identified as being at risk for pressure ulcer development (Patient #'s 1-5), nursing documentation in connection to pressure ulcer prevention and treatment did not meet generally accepted standards of nursing practice. Also, the nursing service did not have a written policy and procedure (P&P) addressing nursing interventions to prevent and/or treat pressure ulcers. Additionally in 2 of 3 MRs reviewed (Patients #6 and #7) of patients receiving pain medication, reassessments lacked documentation in the medication administration record (MAR) of a numerical pain level.

Findings include:

-- Review of Patient #1's MR revealed that on 10/3/16 at 13:08, nursing staff documented a Braden Scale Risk score of 9 (very high risk) with activity subscore of 1 (bedfast) and mobility subscore of 1 (completely limited). At 13:08, nursing documented pressure ulcer prevention measures. However, the documentation did not specify the position the patient was placed in.

-- Review of Patient #2's MR revealed that on 10/4/16 at 9:07, nursing staff documented a Braden Scale Risk score of 12 (high risk) with activity subscore of 1 (bedfast), mobility subscore of 2 (very limited) and sensory perception score of 3 (slightly limited). At 10:11, nursing staff documented that Patient #2 was turned to left side. There is no further nursing documentation indicating that the patient was turned and repositioned until 18:00 on 10/4/16, 8 hours later.

-- Review of Patient #3's MR revealed that on 10/2/16 at 19:56, nursing staff documented a Braden Scale Risk score of 13 (moderate risk) with activity subscore of 2 (chairfast), mobility subscore of 2 (very limited) and sensory perception of 3 (slightly limited). From 19:56 on 10/2/16 to 8:00 on 10/3/16 (12 hours), there was no documentation by nursing staff indicating that the patient had been turned and repositioned. Additionally there was no nursing documentation indicating the position the patient was placed in while in bed from 19:56 on 10/2/16 to 13:14 on 10/5/16.

-- The same lack of documentation regarding turning and repositioning of patients at risk for pressure ulcer development was found in MRs for Patients #4 and #5.

-- During interview of Staff A (Certified Wound Ostomy Nurse) on 10/6/16 at 10:00, he/she acknowledged the lack of nursing documentation in the MR indicating patient position with turning and repositioning.

-- Per interview of Staff B (Chief Nursing Officer) on 10/6/16 at 11:30 am, he/she acknowledged that the nursing department did not have a written P&P addressing pressure ulcer prevention and treatment.

-- Review of Patient #7's MR indicated, on 10/4/16 at 8:51, nursing administered an oral opioid pain medication for a pain level =10, (on a scale of 0-10, 10 indicating the most severe pain). Reassessment of Patient #7's pain was completed at 9:51, nursing documented on the MAR - "yes" (indicating effective). However, there was no documentation of a numerical pain level associated with the reassessment.

-- Review of Patient #6's MR indicated, on 10/4/16 at 11:40, nursing administered an oral opioid pain medication for a pain level =5. Reassessment of Patient #6's pain was completed at 12:40, nursing documented on the MAR- "yes" (indicating effective). However, there was no documentation of a numerical pain level associated with the reassessment.

-- The facility's P&P titled "Pain Management," last revised 6/2016, directed nursing staff, when reassessing a patient's pain, to use the 0-10 numeric pain scale or other rating system that is culturally, cognitively, clinically or age appropriate for the patient.

-- During interview of Staff C (Senior Clinical Informatacist) on 10/5/16 at 14:50, he/she acknowledged the above findings.

Based on findings from medical record (MR) review, document review and interview, documentation of verbal orders (and telephone orders) were not complete. Specifically, in 6 of 6 MRs reviewed (Patients #1,#2,#5, #7, #8 and #9) of patients with documented verbal (or telephone) medication orders, each lacked documentation of a verbal order read back (VORB) by nursing staff. Additionally, the facility policy and procedure (P&P) lacked instruction to staff to document VORB when order received.

Findings include:

-- Review of Patient #1's MR revealed, on 9/28/16 at 7:35, nursing documented a telephone order (TO) from hospitalist for Lasix 40 mg IV (intravenous) x 1 dose now. There was no documentation of a VORB.

-- Review of Patient # 2's MR revealed, on 9/4/16 at 13:20, nursing documented a verbal order from hospitalist for Flagyl 500 milligrams (mg) IV every 8 hours. There was no documentation of a VORB.

-- Review of Patient #7's MR revealed, on 10/3/16 at 15:50, nursing documented a TO from hospitalist for 1 mg Dilaudid IM once for breakthrough pain. There was no documentation of a VORB.

The same lack of documentation by nursing staff of VORB was noted in Patients #5's, #8's and #9's MRs.

-- Per interview of Staff D (Registered Nurse) on 10/5/16 at 14:40, when taking a verbal or telephone order, he/she does not document a VORB.

-- During interview of Staff B (Chief Nursing Officer) on 10/6/16 at 11:30, he/she acknowledged the above findings.

Based on findings from medical record (MR) review, document review and interview, the hospital policy and procedure (P&P) on blood transfusions lacked a generally accepted requirement that the duration of the transfusion needed to be specified in the physician's order.

Findings include:

-- Review of the hospital P&P titled "Blood Component Administration," last revised 8/2016, indicated that Registered Nurses should administer PRBC at 75 milliliter (ml) per hour for 15 minutes and then "120 to 240 ml per hour."

-- Review of Patient #10's MR revealed a physician order dated 10/4/16 at 9:06 to transfuse 2 units of PRBCs (packed red blood cells). No duration for the transfusion was specified.

During interview with Staff B (Chief Nursing Officer) on 10/6/16 at 5:00 pm, he/she acknowledged the above findings.